Nursing Med Term

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  1. A Medical Record is:
    a written document of information describing a patient and his or her health care.
  2. A Medical Record contains:
    dates, observations, medical and surgical interventions, and treatment outcomes provided during hospitalization or visit to a doctor's office.

    It includes: symptoms, medical history, exam results, x-ray reports and lab tests, diagnoses, and treatment plans
  3. Information from medical records could influence...
    one's credit, admission to educational institutions, employment, and one's ability to obtain health insurance.
  4. What does HIPAA stand for?
    Health Insurance Portability and Accountability Act
  5. When was HIPAA passed and what is it?
    1996; HIPAA is a set of rules that doctors, hospitals, and other health care providers must follow to help insure that all medical records, billing, and patient accounts meet certain consistent standards with regard to documentation, handling, and privacy.
  6. What does PHI stand for?
    Protected Health Information
  7. What is Microfilm?
    photographs of records in a reduced size
  8. What is microfiche?
    sheets of microfilm
  9. What does EMR stand for?
    Electronic Medical Record
  10. What does EHR stand for?
    Electronic Health Record
  11. What are the general components that of a patient's chart?
    • 1. Patient Information Form     9. Consultation Reports
    • 2. Medical History                   10. Misc. Reports
    • 3. Physical Exam                     11. Tests/ Lab Reports
    • 4. Consent Form                      12. Operative Report
    • 5. Informed Consent Form      13.Anesthesiology Report
    • 6. Physician's Orders               14. Pathology Report
    • 7. Nurse's Notes                       15. Discharge Summary 
    • 8. Physician's Progress Notes
  12. What does SOAP stand for?
    Subjective, Objective, Assessment, Plan
  13. What is Subjective?
    • Patient's description of how patient feels/ symptoms. Includes chief complaint (CC)
    • Ex: pain, nausea, dizziness, tightness in chest, lump in throat, weakness in legs, butterflies in stomach
  14. What is Objective?
    • Symptoms that can be observed (seen, heard, felt, smelled, or measured). Includes: vitals, data from Physical Exam (PE), general appearance, and condition of all body systems.
    • Ex: Rash, sweating, shakes, dilated pupils
  15. What is Assessment?
    Interpretation of subjective and objective findings. Includes diagnosis or the ruling out a disease or condition.
  16. What is Plan?
    • Management and treatment regimen for patient
    • Ex: lab test, diagnostic tests, physical therapy, diet therapy, medications, medical and surgical interventions, patient referrals, and follow-up directions
Card Set:
Nursing Med Term
2013-01-01 23:11:31
Medical Records HIPPA

Essential Medical Records and Health Information
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